FALLS CHURCH, Va. – Do you have TRICARE For Life? If so, you may know that Medicare and TRICARE For Life work together to minimize your out-of-pocket expenses. After Medicare processes your claim, it forwards the claim to TRICARE For Life for processing. This eliminates the need for you to file a claim. But if you also have other health insurance, also known as “OHI,” you may have to submit a claim in order to receive reimbursement under TRICARE.

OHI is any health insurance you have in addition to TRICARE. Medigap plans and current or former employer group health plan coverage are examples of OHI.

“If you have Medicare, TRICARE For Life, and OHI, each type of coverage is called a ‘payer,’” said Anne Breslin, TRICARE For Life program manager at the Defense Health Agency. “When there’s more than one payer, the order of payment is called ‘coordination of benefits.’ Coordination of benefits rules determine who pays first.”

It’s good to understand how TFL works with OHI. This helps ensure that your claims are paid correctly. Keep reading to learn more.

Reporting your OHI

Medicare doesn’t automatically know if you have OHI. However, insurers must notify Medicare when they’re responsible for paying first on your medical claims.

If you have OHI, you need to tell TRICARE. You can do this by submitting an OHI questionnaire:

• If you live in the United States or U.S. territories, fill out the TRICARE For Life OHI Questionnaire. Submit the form to the TFL contractor, Wisconsin Physicians Service.
• If you live outside the U.S. and U.S. territories, fill out the Overseas OHI Questionnaire and send it to the TRICARE Overseas contractor, International SOS. Or you can update your OHI information in your TOP Beneficiary Secure Claims Portal.

In some cases, your health care provider, employer, or insurer may ask questions about your current coverage so they can report that information to Medicare.

Using OHI with TRICARE and Medicare

“How Medicare coordinates claims with your OHI plan depends on whether you’re 65 or older, if you’re working or retired, and the number of people employed by the employer providing the group health plan coverage,” said Breslin. “Regardless of which of these factors apply to you, TRICARE For Life pays last, after Medicare and your OHI plan.”

Medicare pays first and OHI pays second if one of these scenarios applies to you:

1. You have retiree health coverage (insurance from your or your spouse’s former employment).
2. You’re 65 or older, you have group health plan coverage based on your or your spouse’s current employment, and the employer has fewer than 20 employees.
3. You’re under 65 and have a disability, you have group health plan coverage based on your or a family member’s current employment, and the employer has fewer than 100 employees.

However, your group health plan pays first if one of these scenarios applies to you:

1. You’re 65 or older, you have group health plan coverage based on your or your spouse’s current employment, and the employer has 20 or more employees.
2. You’re under age 65 and have a disability, you have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees.

Lastly, if you have group health plan coverage based on your or a family member’s employment or former employment, and you’re eligible for Medicare because of end-stage renal disease, your group health plan will pay first for the first 30 months after you become eligible to enroll in Medicare. Medicare pays first after this 30-month period.

How to file claims

When your OHI is the second payer, and there’s a remaining patient liability, you must submit a claim for TRICARE to reimburse you for TRICARE’s portion of your claim.

In the U.S. and U.S. Territories: After your OHI and Medicare have processed a claim, you need to submit a paper claim to Wisconsin Physicians Service, with the following supporting documentation:

• An itemized provider bill
• Your Medicare Summary Notice showing what Medicare paid
• The explanation of benefits from your OHI plan showing what it paid
• WPS will process the claim and pay you the portion that TFL covers. You must submit your claim within one year of the date you got care.

If you have any questions about filing claims when you have OHI, contact WPS. The WPS website has instructions and forms for filing secondary claims, FAQs, and more.

Overseas: Medicare doesn’t pay for care you receive overseas, as explained in the TRICARE For Life Handbook. (This doesn’t include U.S. territories.) If you get care overseas with TFL and OHI, you’ll need to file a claim with the TRICARE Overseas contractor to get reimbursed.

Learn more about filing claims overseas and supporting documentation needed for overseas claims.

Learn more about TFL

Looking for more information about TFL? Check out these resources:

• TRICARE For Life Handbook
• TRICARE and Medicare Turning Age 65 Brochure
• TRICARE and Medicare Under Age 65 Brochure
• TRICARE For Life podcasts

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